Fight The Invisible Pain

Chronic pain can and should be managed, so that patients can have a better quality of life

Ms Ma, who is in her early 30s, has a rare inflammatory condition of the blood vessels in her hands and feet. It has led to her having inadequate blood circulation, recurrent infections and ulcerations.

She has lost some fingers and toes due to gangrene and may eventually lose her hands and feet.

That is not all. She is in severe pain all day - a situation she has lived with for the past four years and which is likely to continue.

Her condition may be unusual, but she is not alone.

The World Health Organisation estimates that about 22 per cent of the world's population are living with chronic pain, or pain that persists beyond three months.

Unlike Ms Ma, however, the pain most people suffer from is invisible and, thus, not obvious to others.

Many of my patients put on a brave front, so few people realise they are suffering. They can be experiencing chronic back, neck, joint and nerve pains, all of which may be associated with strokes, diabetes and shingles.

A 2009 survey done in Singapore estimates the number of chronic pain sufferers here to be 8.7 per cent of the population, but this figure is widely believed to be higher.

As doctors, we do know that the chance of having chronic pain rises steeply with age.

In Britain, chronic pain occurs in 62 per cent of those over the age of 75.

With the impending silver tsunami in Singapore, we can expect that chronic pain will become a widespread problem and contribute to the anticipated tenfold increase in elderly healthcare expenditure by 2030.

Here, at the Pain Management Centre in
Singapore General Hospital, patient numbers have risen by about 10 per cent annually since the centre opened a decade ago.

The impact of chronic pain on the individual goes beyond numbers. Chronic pain persists even after one has recovered from an illness and has a big physical, functional, emotional, psychological and social impact.

People with chronic pain are likely to suffer from depression, poor sleep, poor appetite and poor self-esteem.

Many patients I see at the clinic are fiercely independent. They want to care for themselves and walk without the need of aids or wheelchairs, which many perceive as a hallmark of dependence and disability. They want to travel or go out without burdening their loved ones with their physical limitations.

But the persistence of severe chronic pain stops many of them from doing so. Those with severe knee pain are unable to walk even 50m, for instance. Many with severe back pain are not able to stand or sit for prolonged periods of time. This loss of physical ability and independence is often tied to a perceived loss of dignity.

Chronic pain has tremendous influence over a person's thoughts and moods, and patients with chronic pain are three times as likely to have depression or anxiety. Similarly, patients with depression are also three times more likely to develop chronic pain.

Sleep disturbances are commonly experienced by patients with chronic pain. Patients who do not sleep well are also more likely to have chronic pain. This leads to increased stress and impaired cognitive ability. Their ability to carry out simple tasks is also affected.

A night of poor sleep often translates to greater pain the next day and vice versa.

To make it worse, many patients feel guilty about having chronic pain. Their inability to perform domestic chores or carry a toddler often profoundly affects their self-esteem. They feel that they cannot fulfil their roles and responsibilities.

They become irritable, feel lethargic and lose interest in activities, their appetite and the ability to focus on tasks. Inevitably, the patient's relationship with his family and friends is affected.

Chronic pain is also associated with social stigma. In many cultures, expressions of pain are perceived as a weakness as the individual is seen as not being strong enough to overcome or cope with the pain.

Patients may suffer in silence instead of seeking medical attention for their pain. This may lead to low self-esteem and self-worth.

What often compounds the problem is that the pain they experience is invisible. For instance, severe back pain caused by the degeneration of the spine or compression fractures may not be obvious.

The sharp shooting nerve pain that strikes the face unpredictably in trigeminal neuralgia leaves no marks on the skin.

And the constant and unrelenting pin-poking or burning pain due to diabetes is not visible.

Thankfully, chronic pain can be managed.

Take Ms Ma's case. Her pain is complex: There is a constant severe pain in her affected limbs. There are also spikes of severe pain during the changing of wound dressing.

We prescribed her pain medications and she takes stronger painkillers just before the changing of her wound dressings to manage the pain.

Her pain no longer causes her to be constantly irritable. The medications allow her to have a good night's sleep; she is now closer to her son and has fewer emotional outbursts.

She is working with the physiotherapists at the hospital to improve her mobility after the loss of some fingers and toes.

In addition, psychologists and psychiatrists here recognise the impact of pain on her mood and are helping her to manage this through medications and psychotherapy.

Furthermore, medical social workers have helped provide important and essential social support.

All these measures should help to minimise her chances of developing phantom limb pain, after her condition has run its course.

Chronic pain is more common than people think and it can affect anyone. The phrase "I am in pain" should not be a stigma and define who people are.

It is my hope that with greater awareness and understanding, people will start recognising that chronic pain is real and not a weakness.

More importantly, chronic pain can and should be managed to ensure a better quality of life.

Author:
Dr Tan Kian Hian is the head and senior consultant at the department of pain medicine at the Singapore General Hospital.